Provider Demographics
NPI:1932269396
Name:JACOB, SUMA (MD)
Entity Type:Individual
Prefix:
First Name:SUMA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2904
Mailing Address - Country:US
Mailing Address - Phone:612-273-8700
Mailing Address - Fax:612-273-8727
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:SUITE 2A WEST
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-273-8700
Practice Address - Fax:612-273-8727
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN560682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN260003800OtherMEDICARE PTAN
MN1932269396Medicaid